Terminating Patients

Author’s Note: Last month, we handled most of the following question:

“We have a patient who sometimes ‘misbehaves’ during visits by either playing practical jokes on the staff or making inappropriate sexual and politically incorrect comments. What are the steps we should take up to and including dismissal?”

As promised, this article will suggest ways to appropriately handle how to dismiss patients.

In time, every dentist will come across a patient that causes a cringe when stepping foot in the practice. This problem patient could be a nuisance for any number of reasons, such as chronic no-shows, failing to pay bills yet expecting continued service, or even disruptive behavior toward staff.

Can a patient be terminated for any reason? Generally, yes. A dentist needs no reason to terminate the professional relationship, however one should not discriminate against race, creed, gender, age, or disability. By following the parameters in this article, a patient can be dismissed from the practice with the proper notice.

Dentists often tell me that 5% of the patients cause 95% of the problems. Despite this prominent disparity, many dentists feel compelled to retain and treat troublesome individuals indefinitely, most likely due to their caring, compassionate manner, which includes a sense of duty and responsibility toward the healing arts. With careful analysis, a dentist must ask him/herself; "Am I truly serving this patient to the best of my abilities, or have I become biased and would the patient be better off being serviced by another?"

A patient may be safely dismissed from a practice as long as s/he is not "abandoned". A general definition of Legal Abandonment is as follows:

"…the doctor-patient relationship existed, the situation required continued dental care, and the dentist, without giving the patient reasonable notice to enable him to secure proper treatment elsewhere, abandoned the patient when he knew or ought to have known, in the excise of reasonable care, of this need for continued care."

In other words, there are several aspects to consider.

1. Is there any pending dental treatment?

A patient cannot be discharged in the middle of on-going treatment. As a rule of thumb, if you start a procedure, it must be completed before the patient can be discharged. Better yet, ask yourself, “Did God create the problem or did the Dentist?” This does not mean completing an entire treatment plan, but relates to interim conditions created by the dentist and not conditions brought about from ongoing dental disease, injury, and/or neglect.

To give an example, prosthetics provides a simple illustration. If a dentist prepares a tooth for full coverage and places a temporary, s/he must continue to see the patient until the final crown is seated. Prudence also would dictate that at least one adjustment or follow-up visit be allowed. If the dentist refuses to complete the treatment sequence, then the patient would be left with a temporary dentist-created situation where breakdown is both inevitable and foreseeable. The net result would be a dental state that could be worse than the originally diagnosed condition.

A more complicated scenario arises in orthodontics. What happens when a patient discontinues payment in the midst of lengthy treatment? If the dentist initially extracted teeth, thus creating a permanent situation, then treatment should be completed. The dentist can follow practical collection methods in order to collect the fee. On the other hand, it may be permissible to remove the brackets and allow the teeth to resort to the pre-treatment position if no permanent harm will develop.

2. How are emergency treatment situations covered?

The dentist-patient relationship contemplates full care, thus, emergency coverage is expected. Without advance notice of termination, an "active" patient naturally assumes that treatment will be available for any crisis situation. With prior notice of dismissal, the patient has been given the opportunity to find a new dentist and maintain the continuum of care. Thirty days is a reasonable time period in most cases.

The process of dismissing a patient is not difficult, but a dentist must take the following precautions to protect him/herself from abandonment. Once treatment that is started has been completed, written correspondence should be sent to the patient informing of the discharge notice. While the discharge notice in writing is not required for it to be legally binding, it is prudent for a dentist to have written documentation regarding the event. In addition, written correspondence does not need to be sent by certified mail, but it is beneficial to prove receipt.

Following is an example of a discharge notice that I encourage my dental clients to use. Feel free to use this information in your practice.

Dear Patient:

It has become apparent to me that our professional relationship has deteriorated over the past several {weeks/months}. A healthy dentist-patient association is based upon mutual trust, respect and understanding, which are lacking between us. Without assessing blame to you, my team, or me, it seems now is the appropriate time to end our relationship.

You should know several things about your oral condition. There presently is no dental work pending. If you have an emergency situation within the next thirty (30) days, please contact us and we will do our best to accommodate you. Thereafter, we ask that you seek all dental treatment elsewhere.

You also should select a new dentist soon. One potential source is the {State/County} Dental Association referral program at {Telephone Number}. Your condition requires that regular hygiene be performed every {3, 4, 6} months. If you or your new dentist requires copies of your dental records, please send us a written release and we will be happy to forward them to the appropriate person.

My team and I regret that this situation had to occur. We wish you good health in the future.

Very truly yours,
{Dentist Name}

Dismissing a patient may seem like an inordinate challenge and one may reason, “I can handle this block of treatment time”. But as a practitioner, ask yourself, “Am I willing to deal with the mountain of repercussions that may follow?”

Since a small number of people cause a majority of problems in an office, the stress and frustration of having to deal with these people is not worth the angst. Dismiss troublesome patients from your practice sensibly and professionally.